Catching Up on Pediatric Well Visits and Vaccinations in Fall 2021

As we approach the end of summer and the start of a new school year, vaccinations will be at the forefront of health care, especially in our pediatric population. In 2020, shortly after COVID-19 was declared a pandemic, many individuals delayed or forewent immunizations against vaccine-preventable diseases to avoid public exposure during stay-at-home orders. In many cases, the drop was precipitous: For example, data from the Michigan Care Improvement Registry show that fewer than 50% of all 5-month-old babies received their recommended immunizations in May 2020, down from 67.9% in prior years.¹

In 2021, the availability of vaccines against COVID-19 made global headlines. Although these life-changing vaccines are approved
in the United States for individuals 12 and older, health care providers must now return their attention to other necessary immunizations for their patient populations. Pediatric patients may need catch-up vaccinations even as their parents are suffering from “vaccine fatigue” as well as possible post– COVID-19 issues, such as adjusting to children going back to school. This article highlights methods that can be used to boost vaccination rates among pediatric populations, including educating parents about keeping up with routine vaccinations and providing information on immunizing children and adolescents against COVID-19.

COVID-19 TRENDS IN PEDIATRIC POPULATIONS

According to the CDC, the number of pediatric COVID-19 infections in the United States is unknown because of a lack of widespread testing among children and preferential testing in adults and high-risk groups; however, it is known that rates of COVID-19 infection in this population have been rising steadily since March 2020. Although an estimated 16% to 50% of children with COVID-19 are asymptomatic, they can still spread the virus to others.²

Children with confirmed COVID-19 illness have been shown to have a less severe course of disease and a substantially lower hospitalization rate compared with adults2; however, serious complications and sequelae after COVID-19 infection have been reported in some pediatric populations, particularly among those with comorbid conditions.² In May 2021, the estimated cumulative COVID-19 hospitalization rate for individuals age 12 to 17 years was 51.3 per 100,000 population.³ In comparison, during the 2009 H1N1 influenza pandemic, the rate of hospitalization for this cohort was approximately 23.9 per 100,000.³ Additionally, severe hyperinflammatory syndromes following COVID-19 infection have been reported in the general population, and 21% of these occurred in patients age 12 to 17 years.³ Although the rate of infection and course of disease seem to be attenuated in the pediatric population, keeping children healthy and vaccinated against COVID-19, if eligible, in addition to administering their routine vaccinations, will be important in protecting the overall population given the high communicability of COVID-19 and the need to decrease the rates of all vaccine-preventable diseases.

APPROVAL OF COVID-19 VACCINATION FOR YOUNGER PATIENTS

On May 10, 2021, the FDA granted emergency use authorization to Pfizer-BioNTech to expand the use of their COVID-19 vaccine in patients ages
12 to 15 years.⁴ On May 12, 2021, after completing a systematic review of all data collected, the Advisory Committee on Immunization Practices (ACIP) recommended the vaccine for this population,³ and as of July 23, 2021, the CDC recommends that everyone 12 years and older should get a COVID-19 vaccination.⁵ The Pfizer-BioNTech COVID-19 vaccine was the first to receive authorization for this age group, and immunization drives were immediately expanded to include eligible teenagers and preteens.

Evidence for the appropriateness of use of the Pfizer-BioNTech vaccine in this population came from a double-blind, placebo-controlled phase 2/3 clinical trial (NCT04368728) that enrolled 2200 participants (range, 12-15 years) to receive the vaccine or placebo. Efficacy in preventing symptomatic, laboratory-confirmed COVID-19 was shown to be 100% in the vaccinated group (95% CI, 75.3%-100%).⁶ The immune response in the vaccinated group of 12- to 15-year-olds was at least as high as in vaccinated individuals between ages 16 and 25. Safety data demonstrated adverse effects (AEs) in these younger patients similar to the mild-to-moderate ones experienced by patients ages 16 to 25 years. The most common AEs included injection site pain, fatigue, fever, headache, and chills, with the severity increasing after the second dose.³

COVID-19 VACCINE DISTRIBUTION AND ACCESSIBILITY

The COVID-19 vaccine is approved for adolescents aged 12–15 years but not all individuals in this age group are taking advantage of it, because of lack of awareness or access. Community pharmacies should employ methods to ensure that COVID-19 vaccine availability among the eligible adolescent population remains equitable, and that populations in rural areas or areas where health care options are scarce are provided opportunities for vaccination. Also, because access to health care and education about COVID-19 vaccination can differ among certain racial and ethnic groups, community pharmacies in underserved neighborhoods must plan accordingly, perhaps by partnering with school-driven programs and clinics that may reach a broader range of individuals.³

WELL VISITS AND CATCH-UP VACCINATIONS BEFORE SCHOOL

Although COVID-19 vaccinations took center stage compared with routine shots in 2021, inoculation against all vaccine-preventable diseases in pediatric populations remains crucial. The timing of approval for use of the Pfizer-BioNTech vaccine coincides with the upcoming influenza vaccination season; providers can take this opportunity to educate patients regarding the need for protection against flu as well as against COVID-19.⁷ Reducing the risk of hospitalizations and serious infections will be vital as schools and communities reopen. To ensure that the health care system is not overwhelmed, vaccination against both diseases will be essential.

Given the substantial drop-off in routine inoculations this past year, providers need to work with parents to make sure children get all required shots before starting school.⁸ To avoid backlogs, providers will need to inform parents regarding the need to schedule in-person appointments
in time for the upcoming school year and must plan for a surge in office visits.

FIGHTING VACCINE FATIGUE

Parents and guardians of pediatric patients may feel overwhelmed by trying to keep abreast of new information and following modified well-visit schedules to get their children caught up on vaccines. They may also be vulnerable to fear-based misinformation and may display some vaccine hesitancy. Health providers can talk to parents and guardians regarding the need for routine shots and provide realistic timelines for patients to complete them. Tips for addressing vaccine hesitancy are included in the Table.^9-12

VACCINATION SCHEDULES FOR PEDIATRIC PATIENTS

For children between ages 2 months and 6 months, first doses of diphtheria, tetanus, and pertussis (DTaP), Haemophilus influenzae type b (Hib), pneumococcal (PCV13), polio, and rotavirus vaccines will all be indicated for patients who did not receive first doses at their initial well visits. Second and third doses will be indicated approximately 2 and 4 months after initial vaccination, respectively.¹³ Additionally, PCV13, DTaP, and Hib will require a fourth administration. Children between ages 12 and 18 months should have their first doses of chicken pox (varicella), measles, mumps, rubella (MMR), and hepatitis A vaccines. (See ACIP UPDATES VACCINE RECOMMENDATIONS FOR 2021: WHAT PHARMACISTS NEED TO KNOW on page 25.)

Catch-up vaccinations may be less overwhelming for patients after their 2-year well visits, because ACIP recommends subsequent doses of only varicella, DTaP, MMR, and polio vaccines at the 4- to 6-year well visits. Pediatric patients who have completed this milestone will then require an annual influenza vaccine. The human papillomavirus, tetanus, diphtheria, and pertussis (Tdap), and meningococcal vaccines are recommended at the 11- and 12-year well visits. Adolescents then have a break from vaccinations until their 16- through 18-year well visits, when a second dose of the meningococcal conjugate vaccine is recommended.¹³

CONCLUSIONS

Immunization has been the major factor in the eradication of diseases such as measles, mumps, and rubella; the reduction of rates of influenza; and most recently, the mitigation of the spread of COVID-19. Stay-at-home orders assisted in this effort, but also contributed to a significant decline in pediatric well visits during which routine vaccinations are given. With the reopening of school systems, it is important that providers educate parents regarding the need for COVID-19 and other catch-up vaccinations to ensure their children are protected. ACIP provides detailed vaccine schedules for pediatric patients, including catch-up timelines.

Providers should begin disseminating these messages early to ensure children are immunized on schedule, and they need to allocate sufficient time for in-person visits during which issues such as vaccine hesitancy, vaccine fatigue, and other obstacles can be addressed. In this way, we can close the gap in vaccination rates for our most susceptible populations.

Jamie Sison is a PharmD candidate at the Chapman University School of Pharmacy in Irvine, California.

Luma Munjy, PharmD, is an assistant professor of pharmacy practice at the Chapman University School of Pharmacy in Irvine, California.

REFERENCES

1. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic - Michigan Care Improvement Registry, May 2016-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(20):630-631. doi:10.15585/mmwr.mm6920e1
2. Information for pediatric health providers. CDC. Updated December 30, 2020. Accessed July 30, 2021. https://www.cdc.gov/coronavirus/2019-ncov/ hcp/pediatric-hcp.html
3. Wallace M, Woodworth KR, Gargano JW, et al. The Advisory Committee on Immunization Practices’ interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in adolescents aged 12-15 years - United States, May 2021. MMWR Morb Mortal Wkly Rep. 2021;70(20):749-752. doi:10.15585/mmwr.mm7020e1
4. Coronavirus(COVID-19)update:FDAauthorizesPfizer-BioNTechCOVID-19 vaccine for emergency use in adolescents in another important action in fight against pandemic. News release. FDA. May 10, 2021. Accessed July 15, 2021. https:// www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use
5. COVID-19 vaccines for children and teens. CDC. Updated July 23, 2021. Accessed August 4, 2021. https://www.cdc.gov/coronavirus/2019-ncov/ vaccines/recommendations/adolescents.html
6. Frenck RW Jr, Klein NP, Kitchin N, et al; C4591001 Clinical Trial Group. Safety, immunogenicity, and efficacy of the BNT162b2 COVID-19 vaccine in adolescents. N Engl J Med. 2021;385(3):239-250. doi:10.1056/NEJMoa2107456
7. What are the benefits of flu vaccination? CDC. June 8, 2021. Accessed July 1, 2021. https://www.cdc.gov/flu/prevent/vaccine-benefits.htm?web=1&wd-LOR=c42DD8B4B-1CD6-4232-A70F-530EDBEE744D
8. Vaccines and immunizations. CDC. February 16, 2021. Accessed June 30, 2021. https://www.cdc.gov/vaccines/index.html?s_cid=PN-NCIRD-LifeSpan-PDF-vaccines-6
9. Vaccine resources to share with parents. CDC. March 18, 2019. Accessed July 1, 2021. https://www.cdc.gov/vaccines/hcp/conversations/resources-parents.html
10. Catch up on well-child visits and recommended vaccinations. CDC. June 17, 2021. Accessed on June 30, 2021. https://www.cdc.gov/vaccines/parents/ visit/vaccination-during-COVID-19.html
11. Common vaccine safety questions and concerns. CDC. July 17, 2020. Accessed July 1, 2021. https://www.cdc.gov/vaccinesafety/concerns/index.html
12. Vaccine resources for parents. CDC. April 15, 2016. Accessed July 2, 2021. https://www.cdc.gov/vaccines/parents/resources/index.html
13. Immunization schedules. CDC. February 11, 2021. Accessed June 30, 2021. https://www.cdc.gov/vaccines/schedules/index.html